Authors' objectives: Sustaining independence is important for older people, but there is insufficient guidance about which community health and care services to implement. To synthesise evidence of the effectiveness of community services to sustain independence for older people grouped according to their intervention components, and to examine if frailty moderates the effect. The number and proportion of older people are growing in the UK and worldwide. Maintaining independence is a goal of community health and care services for older people. The concept of frailty can be used to distinguish between people who remain in robust health in later life and those who are at greater risk of losing independence and needing care. Previous research has suggested that community-based complex interventions are generally effective for supporting independence for older people, but only broad service models have been explored. There is insufficient guidance about which services to implement and the appropriateness of different services for different levels of frailty. We aimed to provide a rigorous, contemporary synthesis of trial evidence to identify how interventions might best be configured to improve outcomes for older people, and inform the commissioning and delivery of evidence-based services. Do community-based complex interventions to sustain independence in older people increase living at home, independence and health-related quality of life? Do community-based complex interventions to sustain independence in older people reduce homecare usage, depression, loneliness, falls, hospitalisation, care-home placement, costs and mortality? How should interventions be grouped for network meta-analysis (NMA)? What is the optimal configuration of community-based complex interventions to sustain independence in older people? Do intervention effects differ by a population’s frailty level (robust; pre-frailty; frailty)?

Authors' results and conclusions: We included 129 studies (74,946 participants). Nineteen intervention components, including ‘multifactorial-action’ (multidomain assessment and management/individualised care planning), were identified in 63 combinations. The following results were of low certainty unless otherwise stated. For living at home, compared to no intervention/placebo, evidence favoured: multifactorial-action and review with medication-review (odds ratio 1.22, 95% confidence interval 0.93 to 1.59; moderate certainty) multifactorial-action with medication-review (odds ratio 2.55, 95% confidence interval 0.61 to 10.60) cognitive training, medication-review, nutrition and exercise (odds ratio 1.93, 95% confidence interval 0.79 to 4.77) and activities of daily living training, nutrition and exercise (odds ratio 1.79, 95% confidence interval 0.67 to 4.76). Four intervention combinations may reduce living at home. For instrumental activities of daily living, evidence favoured multifactorial-action and review with medication-review (standardised mean difference 0.11, 95% confidence interval 0.00 to 0.21; moderate certainty). Two interventions may reduce instrumental activities of daily living. For personal activities of daily living, evidence favoured exercise, multifactorial-action and review with medication-review and self-management (standardised mean difference 0.16, 95% confidence interval −0.51 to 0.82). For homecare recipients, evidence favoured the addition of multifactorial-action and review with medication-review (standardised mean difference 0.60, 95% confidence interval 0.32 to 0.88). Care-home placement and service/economic findings were inconclusive. Findings for the many intervention combinations evaluated were largely small and uncertain. However, the combinations most likely to sustain independence include multifactorial-action, medication-review and ongoing review of patients. Some combinations may reduce independence. We screened 40,112 records and assessed 973 reports for eligibility. We included 129 studies consisting of 496 reports. The studies assigned 74,946 participants (three studies missing data) to 266 eligible intervention arms. They were predominantly conducted in developed countries and most participants were described as white. Nonetheless, the overall population included a broad range of demographic characteristics. Study populations included all frailty levels. We identified 19 separate components of included interventions which were evaluated in 63 combinations including the absence of all of these components, which we termed available care (ac), and homecare (a common control group in populations where all participants were receiving homecare). Homecare involved frequent visits at home by professionals who typically supported domestic and self-care tasks. Five components were primarily about a process of ascertainment or assessment and planning with subsequent action: multifactorial-action from care planning (a process of individualised multidomain assessment and management) with or without routine review (scheduled, regular follow-ups), medication-review, monitoring and routine risk-screening. The 14 other components and their short labels (bold) were ADL training, providing aids and adaptations, alternative medicine, care voucher provision, cognitive training, health education, physical exercise, formal homecare, engagement in meaningful-activities, nutritional support, psychological (mood) therapy (psychology), social skills training, technology for communication and engagement (telecoms), welfare rights advice. Multifactorial-action was further delineated based on the presence or absence of an embedded medication-review and specific self-management strategies. We judged most results to be at high RoB, primarily due to missing outcome data. This led to serious concerns with RoB for many of the GRADE ratings of evidence. Findings Most networks were small and sparse, with few included studies contributing to most networks. We found little evidence of inconsistency but there was usually low power to detect this. All outcomes except mortality needed to be analysed in two separate NMAs as the networks were disconnected: one with ac as the reference comparator (‘available-care network’) and one with homecare as the reference comparator (‘homecare network’). Estimates are reported here only in comparison with the reference comparator. Comparisons with ac can be thought of as the effect of adding the intervention for a population who are not all receiving any particular care; comparisons with homecare are similarly an alternative intervention for a population already in receipt of homecare without associated reablement or multifactorial-action from care planning. Most estimates were low certainty or very low certainty due to RoB, imprecision or their combination, and we do not describe very low-certainty evidence below. Living at home For living at home in the medium term there were 21 studies (n = 16,937) with 14 intervention groups in the available-care network. There was moderate-certainty evidence that multifactorial-action and review with medication-review probably results in a slight increase in the chance of living at home [odds ratio (OR) 1.22, 95% CI 0.93 to 1.59; moderate certainty]. There was low-certainty evidence that multifactorial-action with medication-review [OR 2.55 (large), 95% CI 0.61 to 10.60]; cognitive training, medication-review, nutrition and exercise [OR 1.93 (large), 95% CI 0.79 to 4.77]; and ADL, nutrition and exercise [OR 1.79 (large), 95% CI 0.67 to 4.76] may result in an increase in the chance of living at home, and that risk-screening; education, multifactorial-action and review with medication-review; and education, multifactorial-action and review with medication-review and self-management may each result in some reduction in chance of living at home. Other comparisons with ac were of very low certainty. In the short- and long-term time frames, results were at best low certainty. For multifactorial-action and review with medication-review; and ADL, nutrition and exercise, estimates were similarly of small increases in the long term but of little to no difference in the short term. There were similar results in other time frames for education, multifactorial-action and review with medication-review and self-management; and risk-screening, but contrasting evidence of reduction followed by an increase in living at home for education, multifactorial-action and review with medication-review. The homecare network for living at home was smaller (five studies, n = 1978 in the medium term). In the short- and medium-term time frames, there was low-certainty evidence that homecare, ADL, multifactorial-action and review with self-management may result in a moderate or large reduction in the chance of living at home compared with homecare alone. Available evidence suggests the community-based complex interventions most likely to sustain independence in older people involve multifactorial-action from multidomain assessment and individualised care planning, routine review and the incorporation of medication-review. There was also some positive evidence for the combination of exercise and nutritional support and multiple other intervention combinations. Decision-makers should be aware that there is plausible evidence that some community-based complex interventions may worsen outcomes such as living at home and ADL independence and that all of these findings are tentative. We recommend the uncertainty in these findings be addressed by: realist synthesis to explore the mechanisms and broader contextual factors relating to individual benefit or harm future robust, large-scale trials which compare alternative interventions with multifactorial-action and review with medication-review future Individual Participant Data meta-analysis (IPDMA) focusing on interventions with multifactorial action to explore factors relating to individual benefit or harm greater reporting of the organisational aspects of intervention implementation in complex intervention research.

Authors' methods: We searched MEDLINE (1946–), Embase (1947–), CINAHL (1972–), PsycINFO (1806–), CENTRAL and trial registries from inception to August 2021, without restrictions, and scanned reference lists. Interventions were coded, summarised and grouped. Study populations were classified by frailty. A random-effects network meta-analysis was used. We assessed trial-result risk of bias (Cochrane RoB 2), network meta-analysis inconsistency and certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation for network meta-analysis). High risk of bias in most results and imprecise estimates meant that most evidence was low or very low certainty. Few studies contributed to each comparison, impeding evaluation of inconsistency and frailty. Studies were diverse; findings may not apply to all contexts. Systematic review with NMA of trials evaluating community-based complex interventions to sustain independence in older people (mean age 65 years and over), compared with usual care or another complex intervention meeting our criteria, with follow-up for at least 24 weeks. We followed Cochrane methods, Grading of Recommendations Assessment, Development and Evaluation (GRADE) and Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) NMA guidance. Information sources We searched the following databases and trial registers from inception between 9 and 11 August 2021: Cochrane Central Register of Controlled Trials (CENTRAL) Wiley (1992–); MEDLINE Ovid (1946–); Embase and Embase Classic Ovid (1947–); CINAHL EBSCOhost (1972–); APA PsycINFO Ovid (1806–); US National Institutes of Health Ongoing Trials Register, ClinicalTrials.gov (www.clinicaltrials.gov); World Health Organization, International Clinical Trials Registry Platform (https://trialsearch.who.int). We scanned the reference lists of included studies.

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hta/NIHR128862

Year Published: 2024

URL for published report: https://www.journalslibrary.nihr.ac.uk/hta/HNRP2514

URL for additional information: English

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: United Kingdom

DOI: 10.3310/HNRP2514

Organisation Name: NIHR Health and Social Care Delivery Program

Contact Name: Rhiannon Miller

Contact Email: rhiannon.m@prepress-projects.co.uk